Knock Knock Eye: The Real Horror in Nosferatu? His Corneas
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What's happening, y'all? It's Anthony Edwards. The open earbuds are great, especially for when you're warming up for pregame. You like to hear the sound of the ball, but you want to hear the music, but you also got to hear your coach. Super dope, because it gives you the best of both worlds. Check out Bose.com for more. Today's episode is brought to you by Microsoft Dragon Co-Pilot, your AI assistant for clinical workflow, which helps to ease administrative burdens. Those...

Lots of burdens. Lots of burdens. Automatically document care, streamline workflows, and promote a more focused clinician-patient experience. I know you love that. Yes, I do. Learn about how Dragon Co-Pilot can transform the way you work. Visit aka.ms slash knock knock high. Again, that's aka.ms slash knock knock high. Hey, Will. Hey, what's up? I've been thinking. The

The U.S. healthcare system, it needs some improvement. Yeah, there's room for improvement. Yeah, it's a confusing, scary place for everybody involved. Absolutely. Physicians, families, patients, everybody. Everybody. And I've experienced it from both sides, right? I'm a physician. I've also been a patient. So I wanted to use my platform to give people practical education, really the only way that I know how.

By making jokes. So Dr. Glockenflecken's really fun and super uplifting guide to American healthcare is out. And it's a free resource that includes all my videos from the 30 Days of Healthcare series, alongside deeper explanations, also reliable facts, emphasis on reliable. Yes. All right. Figures, numbers, insights into how each of us can fight for a more humane healthcare.

better healthcare system. Also, it has jokes. Did you mention the jokes? I did. Jokes. Yes, definitely jokes. Well, this guide is great for anyone looking to learn more about U.S. healthcare, but especially if you are experiencing it from the clinician side for the first time. We really hope you'll check it out. Get the free guide sent straight to your inbox by signing up for our mailing list, glockenflecken.com slash healthcare. Enjoy.

Knock, knock. Hi.

A little bit later. First, I want to thank all of you who commented on the, as of this recording, the most recent Knock Knock Eye episode that was about a surgical complication that I had. I took you through kind of every aspect of it, what happened, how the complication occurred, how I managed it, what I talked to the patient about. And then I...

use this metaphor that I always think about whenever something negative happens in my job and, or something doesn't go quite right about, uh, how a medical career is kind of like climbing a mountain. And, um, uh,

And so I won't rehash the whole metaphor, but go back and check it out on our YouTube channel. You can find that episode. I had a surgical complication. Here's how I dealt with it. And I just want to say I appreciate everybody who gave me some feedback.

and um and positive comments about it people really like the the the thinking about it in terms of this uh you know climbing a mountain metaphor uh and um it just it really helped me it made me feel good that you know i'm not the only one uh which you know is always a good thing to uh to know that you know and it's not just it's also not just medicine that was the interesting thing

I heard from people who are lawyers and kind of experience, have the same feeling when things don't go wrong because everybody has quote unquote complications that occur in their job, whatever it is, things don't always go right. And we can all learn from each other. And so it was really nice to see all of that. I appreciate that. Um,

During that episode, I also mentioned making a giant 6mm incision. A giant 6mm incision at Riley's 8095 said, that really puts into perspective how small everything is in ophthalmology. Yes, that made me laugh. Yes.

It does sound ridiculous to say an enormous six millimeter incision that I might have to make that everything is relative in ophthalmology. Very, very small. And so, yeah, if you want, you can definitely read through all these comments. I won't get to a lot of them today because I got a lot of other stuff I want to talk about. One of those things I want to talk about is I posted my first video where I use first aid

for the USMLE exam to randomly select a topic to make a video about, trying to just make random things in medicine funny and get people to learn about them. So I posted the first one on all my platforms. It was about thoracic outlet syndrome, and it's going great. I actually really love it. It's like now I have...

thousands of ideas that I could come up with. Just doing this, picking a random page and then picking a topic on that page in this 700 page book. Now I have so many things I can make videos about, but what was really, really cool to see were the comment section on this video on YouTube, on TikTok and on Instagram, where it was, I had people who were patients and

talking about their experience with thoracic outlet syndrome, you know, getting, having a rib removed. I just, I guess I can just tell you what this syndrome is. Uh, but it's basically something you have. Sometimes it's just your, your own anatomy. Sometimes you have like an anomalous first rib, but basically what ends up happening is your anatomy in some way causes, uh, an obstruction of the major blood vessels going from, uh,

you know, your neck down into your arm typically. So like the subclavian artery is the classic example, right? So you have like an anomalous first rib or something that obstructs the subclavian artery so you have a lack of blood flow to the arm and it can cause weakness, it can cause

pain, swelling, just, it can be a really serious problem. And so I made a video about this syndrome and I had patients, people who have this, who were talking about their experience with getting a rib removed, a ribectomy as I call it in the video. But also I heard from like

Like medical professionals who treat this because I don't treat it. Right. I'm just I'm just using a textbook and I'm just making a video about the text in the book. I don't have any personal experience with this, although I did see one. I did see a rib removed once and it was like basically like a fancy pair of hedge clippers. Just just took it out. Really cool.

Yeah, not quite hedge clippers, but I forgot, like a tree fine? I don't know. I don't know what the thing is called. But it was fascinating to watch. And so in my comment section, I had patients talking about their experience from the patient side and physicians talking about their experience from the physician side. Some of them gave me some other more in-depth information. And then you just... So it's just cool to see like...

people talking to each other, right. And learning from each other. And if, if that, I'm going to keep doing it because I love to see that because we need like more constructive conversations and discussion and,

between people in the medical field and outside the medical field. Because there's a lot of contentious, there's lots of anger, there's contentiousness, if that's even a word, I don't know. But just people butting heads about vaccines, about all the terrible things that are happening in healthcare. So it's kind of nice to see people just talking about medicine, talking about a disease and treatments. And I don't know, it's fun. It's fun to see. So I'm going to keep doing it.

The only downside is I just I prepped. I did the prep for the next one that I'm going to do. And the random page I chose was in the biostatistics section of first aid. And so now I got to do a video on the Kaplan-Meier curve. You know, no one said it was going to be easy.

I have an idea. I've got to brainstorm how to make that interesting to people. That's on my list of things to do. Today, I am feeling hopeful about the healthcare system. I know I have a lot of negative things to say about the US healthcare. There are a couple states that are

actively as of this moment working on pbm reform that's a that's a great thing uh mississippi and texas as well there i think texas actually has like hearings that are that are happening today or tomorrow this week uh the point is though and whether or not these things like go anywhere who knows but people are taking it seriously it's happening

I've told you guys like PBM reform is, is like top of my wishlist right now. It's like definitely top three that allowing, you know, physicians to own hospitals, increase some competition in our healthcare system, uh, uh, prior authorization reform. There's a ton of things, but PBMs like of all the middlemen within the medical field, uh,

They're the most middle of all the middlemen of the PBMs. They are totally unnecessary. Don't let anybody tell you otherwise. We don't need PBMs to do anything. All they do is extract money from the healthcare system. So I'm encouraged to see states

legislators taking this seriously and looking into it and learning from pharmacists, learning from physicians, health policy experts, and then really taking it seriously to try to reform this thing. Scaling back DIR fees is another part of that, which we've had some success in doing as well. I made a video about that a while back because that was something I didn't even know. Basically, it's like

There are these fees that the PBM will impose on a pharmacist, on a pharmacy, and basically clawing back some of the money that was given to that pharmacy, sometimes like six months prior. So like the pharmacy, the PBM, the insurance company will pay the pharmacy for this medication.

And then the PBM would be like, oh, wait, we're going to charge you a fee for that. And then six months later, like tell the pharmacy, oh, hey, you owe us X amount of money for this medication you filled six months ago. And it's something that they like it's impossible to plan for. Right. I run a business, a business. I that would be.

almost impossible and irritating and just a mess to try to like keep track of that six months down the road. So anyway, all these things that make it really hard for independent pharmacists to stay open. So there's a thousand reasons why PBM reform needs to happen and it's starting to happen. So that's great. Let's take a break. And then I will, I'm going to talk to you about Nosferatu.

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Yeah. Does that make you feel better? No. Like they're passed down through close contact, especially between mothers and babies. Oh, wow. Such a special gift for our daughters. They're born, they live, they crawl around, and then they die on your eyelids and in your lash follicles. Their entire life cycle lasts about two to three weeks, all spent on your eyelids. Well, thank you for that. This isn't helping, is it? No. How do I get rid of them? Well, it's...

It's fun to gross you out, but we do have all of these. It's really common, but there is a prescription I drop to help with these now. Okay. That probably excites you. That makes me feel better. Any way to get rid of them, right? That's right. All right. Sign me up. Visit MitesLoveLids to learn more about demodex blepharitis, which is the disease that these little guys cause. Sure. Again, that's M-I-T-E-S.com.

Love Lids, L-O-V-E-L-I-D-S dot com to learn more about Demodex and Demodex Blufferitis and how you can get rid of it. Every day, thousands of Comcast engineers and technologists like Kunle put people at the heart of everything they create. In the average household, there are dozens of connected devices. Here in the Comcast family, we're building an integrated in-home Wi-Fi solution for millions of families like my own.

It brings people together in meaningful ways. Kuhnle and his team are building a Wi-Fi experience that connects 1 billion devices every year. Learn more about how Comcast is redefining the future of connectivity at comcastcorporation.com slash Wi-Fi. All right, here we go, guys. I watched a movie yesterday. I promise this is eye-related. I'm not going to transition into like a movie critic podcast here.

i watched nosferatu the um not the original from like the 1920s or something this was the one that was that was made last year it got some some oscar nominations

I like horror movies. I'm a big fan. Finally got a chance to watch this one. So Nosferatu, if you're not familiar with it, it's like set in the 1840s or something in some German. It's a very Victorian village. The plague makes an appearance during the movie. But basically the general plot is that there's this Count Orlok who is Nosferatu, who's a vampire.

never really call him a vampire during the movie but he's a vampire he sucks blood from people he lives in a coffin uh he only comes out at night and it's all about how nosferatu wreaks havoc on this village and death and despair happen and and and you know so watch the movie it's actually a really good movie i i really did enjoy it um but the reason i'm bringing this up

is because it was very clear pretty much immediately, once we got a good look at Nosferatu's face, the man has severe, severe corneal scarring in both eyes. It's puzzling because he still clearly has decent vision because he's able to very, with great accuracy and precision, latch onto people's necks

from a great distance quickly so he's got some vision he's got he can see which doesn't quite go along with the degree of corneal opacity that um mr nosferatu has

And so it got me thinking, because I'm crazy, it doesn't make any sense. I was like, why? What happened to him? Why does he have such severe corneal scarring? It's like, it's white. It's a white-out cornea. At first, I was like, okay, well, is it really the cornea? And it's clear. It's not the cataract. I'm sure, though, if he's hundreds of years old, he's got very dense cataracts.

But it's clearly the surface of the eye. All right, the corneas. So what could this be? So what I want to talk about for this episode is causes of corneal blindness. All right, what are the most common causes of corneal blindness? Well, the conversation has to start with infection. All right, now, the obvious nowadays in today's world, the obvious culprit is contact lens wearers.

You know, you wear your contact lens, you sleep. That's why I'm always griping about people sleeping on their contact lenses. Don't do it. I know some of you listening, you're sleeping in your contacts every night. Don't do it. No, it's not worth it. You only get one cornea. I mean, I guess you could get a second cornea because it's corneal transplants exist, but you don't want to have to go through that. All right. Don't sleep. Take your contacts out. That just does do it. Anyway, corneal blindness can be caused by infection caused by a, uh, you know, overuse and abuse, uh,

Of your contacts. The problem with Nosferatu is that this took place, this movie took place in 1840. The first contact lenses were fitted in 1888. So definitely not the case. So it wasn't contact lens related. Bacterial keratitis,

unlikely to get that unless you got some significant trauma. Now, could he, he's attacked and killed a lot of people and chances are somebody fought back. Could he have gotten an infection from there? Entirely possible, entirely possible. It didn't strike me though, as a, a, a whiteout from an infection though, because often those end up, if you, if they're not treated, they're severe enough, which, which,

This German village, you guys, not the most hygienic place to live. All right. So it wouldn't surprise me if there's some nasty stuff in the water there. And so, but it didn't strike me as a cause for Nosferatu's blindness because oftentimes with severe bacterial infections, you get melting of the cornea, which will result in an open globe injury followed by tisis of the eye.

Tisis is basically like an involution of the tissue, just your entire eyeball just atrophies. Nosferatu's eyeballs looked like a normal size. So there was no tisis. There was no death of the eyeball itself that was happening. He had normal sized eyeballs. It was just cloudy corneas.

And so I don't think there was any kind of ulceration from a bacterial infection resulting in an open globe injury. And then ultimately a ticycle eye is the, what would we call it? Don't try to spell that. It's, I can't even spell it. That's a hard one. P S P H T P H T H.

I-S-I-C-I-A-L. There's a P-H-T-H. That's a real thing. That's an actual combination of letters that we use in ophthalmology. All right, so bacterial's out. It's not bacterial. Fungal. Could it be fungal? So usually you see fungal infections in tropical, like more humid places.

hotter environments. We're like in the highlands of Germany here and it looks cold. It's probably cold all the time. He's in a drafty castle. Uh, not, not really maybe fungal. It's, it's possibility, but I still think it's unlikely. Um, now trachoma,

Now, trachoma is caused by chlamydia. This is actually the most common cause. It might be the most common cause of corneal blindness in the world. Now we're talking. Now we're getting there. Again, not a very hygienic place. Could Nosferatu have rip-roaring chlamydia trachomatous infection causing trachoma of both eyes? This is probably the most likely infectious disease

potential cause for nosferatus corneus herpes simplex is another one herpes i mean you know you live long enough and who knows how old nosferatu is he's got to be hundreds if not thousands of years old uh at some point he got himself some hsv all right it's been living in his nerves all right by the time he is a thousand years old he's got to have multiple

multiple occurrences of HSV keratitis. That could certainly cause

Neovascularization of the cornea, that's one of the big things with HSV keratitis is you get this influx of abnormal blood vessels into the cornea that can ultimately cause scarring. And you get this process called conjunctivalization of the cornea. Basically, the conjunctiva just kind of grows over the cornea as a way to try to heal it from persistent infection.

Now, the problem with HSV is that typically it's only one eye, but he's living long enough, decades, centuries, multiple reoccurrences of infection. Could he eventually get it in the other eye? Probably. All right. But I still think maybe trachoma, it looked a little bit more like a trachoma type of corneal opacity. Other causes, trauma. We've talked about this. Yeah, definitely. Trauma is a possibility here.

I mean, come on. The guy, who knows? He's lived through, you know, OSHA regulations did not exist. I don't know what he's done for work over the centuries, but chances are he was probably doing something dangerous at some point in his life, could have easily had trauma that caused corneal scarring. How about corneal dystrophies? I think this is of the non-infectious causes of corneal blindness. I think corneal dystrophy is,

Is certainly possible here. So the most common ones that can cause blindness would be keratoconus, which is an irregular astigmatism. You get thinning of the cornea. You get kind of a cone-shaped appearance. And you can have what is called corneal hydrops, where you have such severe stretching of the corneal tissue in someone with keratoconus that it can actually cause

rupture certain layers of the cornea, the decimase membrane that cause a huge influx of fluid into the cornea. And the cornea does not need fluid in it. It's supposed to be totally without fluid

That's how you keep it clear. That's how you keep seeing through your cornea is by keeping fluid out. And you have cells in your cornea. Their whole purpose is to pump fluid out of the cornea and keep it totally clear. But

If you have a corneal hydrops episode because you have keratoconus that it can cause, all of a sudden you don't have those layers. They're not able to do the job they're supposed to do of pumping fluid out of the cornea. And so all the fluid can come rushing in. You get this severely swollen cornea. And if you don't treat it with modern technology and usually eventually corneal transplant,

then you'll just end up with permanent scarring. That's a possibility. Maybe old Nulsferatu has a little bit of keratoconus going on. Wouldn't shock me. Fuchs dystrophy is the other one that I'm thinking of. We see Fuchs dystrophy more common in Northern Europeans. I don't know what Count Orlok's ancestry looks like. He sounds like he could be like

Viking. It kind of looks like it too, but that just could be the vampirism. Anyway, Thux Dystrophy. I think I maybe talked about this before.

This is a disease where you have a dysfunction of the corneal endothelium that causes swelling of the cornea, and then you can end up doing a transplant to treat it. It's actually a very easily treatable thing now with our current transplant technologies. And so let's see where we're at here.

All right, a couple more causes, and then we'll get to what could Nosferatu do for this? I would say, so we talked about infectious causes, trauma, inherited causes of corneal blindness. Let's see, here's one, vitamin A deficiency. Now, I think with the amount of blood that Nosferatu consumes, I don't think he's struggling with vitamin A.

I think blood has vitamin. The point is, I think he's getting enough. He's getting enough vitamin A with his diet for sure. So that's, you're not going to get what's called xerophthalmia, which is a condition that can cause this like foamy deposition on the surface of the eye leading to corneal damage and eventually blindness. So Nosferatu's blindness is somewhere in those things that I mentioned. I think trachoma is a big one and probably some kind of corneal dystrophy.

That's probably what we're going with here. All right, let's take one more break, and then we'll come back and talk about some treatment of corneal blindness. Hey.

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All right. Now, the hard thing for Nosferatu, he's a deformed vampire in the 1840s. There's not a lot of technology available to him to try to treat his blindness.

So sometimes we have eye drops that can treat corneal edema, basically hypertonic drops that can suck out the moisture from the cornea and keep it nice and clear. But then for a lot of these things, you're looking at a corneal transplant. Our corneal transplant technology, our ability now is unbelievable what we can do. 30, 40 years ago, all we had available to us is a full thickness corneal transplant.

so when you're an organ donor and you don't have anything precluding your ability to to donate your cornea like you've never had lasik you've you've never had a corneal significant corneal infection you don't have any any the cause of death wasn't related to you know sepsis something that could um deposit bacteria into the cornea um

Anyway, there's different criteria, but assuming you're able to donate your corneas, it's a wonderful gift that you can give to somebody. Because at first we had full thickness transplants. That's the most common transplant used for diseases that affect the entire thickness of the cornea.

So we're talking keratoconus is probably the most common reason someone might get a full thickness corneal transplant, what we call a penetrating keratoplasty. And you'll see, and these patients do very well with a penetrating keratoplasty. The benefit, the great thing about corneal transplants, as opposed to other organs that you can transplant, is the cornea doesn't have

really a blood supply. The cornea gets its nutrition from the aqueous, from the tear film. It doesn't need blood vessels. That's why the cornea is as clear as it is to allow you to see because it doesn't need a bunch of blood vessels that would be blocking your vision. And so you don't have as big of a risk of rejection. Now, can you get rejection of a corneal transplant? Absolutely. It does happen.

But you're not taking a ton of immune suppression medication to try to keep that happening, to keep that from happening. And so people with keratoconus who had a full thickness transplant, they'll have that transplant sometimes for 30 years, seeing well and not having to take any medications. And it's unbelievable. And so for a long time, that's all we had was the full thickness thing.

And then we started experimenting. Well, there are certain causes of corneal blindness that only affect certain layers of the cornea. So you have the epithelium, that's the outermost layer of the cornea. You have the stroma, that's the meat, that's the middle part of the cornea. And then on the inside of the cornea, you have what's called decimase membrane, and then your endothelial cells. That's those pump cells I was telling you about.

So we have certain diseases like Fuchs dystrophy that only affect the inside layers. And so we started experimenting with just transplanting certain layers of the cornea. So we would just do what's called a desec, where we just take out the diseased endothelium and decimase membrane.

And you insert inside the eye a donor decimase membrane and endothelium and use an air bubble to push it up against the inside of the cornea. It's called a desec. And that's extremely effective. And then we went even further. And now we have what's called a DMEC, where all we're doing is basically transplanting, sorry, the desec.

transplants a little bit of the stroma as well. In addition to the decimase, a DMEC is just decimase membrane and endothelial cells. So we're getting thinner and this is a very, very thin tissue. So we're just, you know, segmental transplants of the corneas. It's amazing. Unfortunately for Nosferatu, really, if he was going to get

a transplant, it'd have to be a penetrating keratoplasty. And then in order to see well, he might need like a special scleral contact lens because, you know, I'm almost positive that

He'd have irregular astigmatism after his penetrating keratoplasty. But also, there's probably a 90% chance he'd end up with a post-op infection. Watch the movie. Look at the type of environment this vampire is living in. It doesn't have anybody cleaning his castle for him.

Even his food, the people he eats, the blood he gives to these people, they're not clean either. He's not washing the necks before he sucks the blood out of them. Although really in this movie, it's more the chest. It's weird. Anyway, so I worry. I'm afraid that he probably spent most of his life blinded.

And maybe he just has a tremendous sense of smell to be able to pinpoint where his food sources are. Otherwise, I'm not sure how he navigated the world. He wasn't using a white cane. There was no Braille involved. He could read a document and sign it.

which was interesting. I'm still puzzled how he was able to do some of the things he was able to do without adaptive devices that we have today. Anyway, it's interesting. So the lesson here is don't watch a movie with me

Because, or probably any doctor, we just ruin it with this type of thing. So anyway, those are my thoughts on Nosferatu and corneal blindness and treatment of corneal blindness. That's all I have for you today. Let's see, do I have any other comments I could share? Oh, here's one more comment. This made me laugh. So in the last episode that went up, I think I had a comment from somebody

who was in Wisconsin, didn't have great vision, but because they're in Wisconsin, they have very lax driving laws. They were still able to get a license to drive. And so at MindHacks said, I'm from Wisconsin. That doesn't surprise me. We are lax on many things related to driving due to all the DUIs. Of the top 10 drunkest cities in the country, we hold five or six of the top 10 spots.

driving here is scary. Well, all right, be careful, folks. Be careful going to Wisconsin. I've never driven in Wisconsin, but that all makes sense. Some people are also wanting Ma Glonkinflecken to appear in a future video. I'll have to work on that. Yeah, anyway, thanks for the comments, you guys, and thanks for sticking around for this episode and letting me talk about Nosferatu, who should not be driving.

Fortunately, I think he's got somebody driving his carriage for him, overloading his coffin onto the carriage to go across the sea to haunt this town. Anyway...

I appreciate you. Leave reviews and feedback if you want. Maybe not on this episode, but we do appreciate that. Also, leave comments. YouTube channel at Glockenfleckens. I go through all of those every week and love seeing what you guys have to say.

And check out all my videos too, especially as I'm going through this random medicine topics. I think it's going to be a lot of fun. And we'll see what hits, what people like to see with that, what people don't. I don't really have any control over it because I'm using a random number generator to randomly choose a page and make a video about it. So we'll just have to see what happens.

I am your host, Will Flannery, also known as Dr. Glockenpluckin. Thanks to our executive producers, Aaron Courtney, Rob Goldman, and Shanti Brooke. Editor-in-chief is Jason Portiza. Our music is by Omer Binzvi. Knock Knock High is a human content production. We'll see you next time, everyone. Bye! Knock Knock, goodbye! Human content.